Lower back pain is one of the most common complains you can have in a remedial clinic. And there are so many contributing factors to this type of pain and many elements that can influence pain and discomfort in this area. With 16% of the population of Australia suffering from acute back pain and alomst 70-90% of Australians predicted to experience lower back pain in their life, theres a lot of effort and energy put into treating, diagnosing and managing this condition. An often undiagnosed contributor to lower back pain can come in a condition that affects 10% of the population is Bertolotti’s Syndrome. This condition involves stenosis or fusing of the transverse process of the 5th lumbar vertebral segment to the sacrum and whilst many people don’t know they have it, it can be an undiagnosed cause of lower back pain.
Bertolotti’s Syndrome is accredited to Mario Bertolotti, an Italian physician who first termed the condition in 1917. A sacrilisation occurs when the transverse process of the 5th vertebra fuses with the uppermost segment of the sacrum. Technically this is termed a Lumbrosacral Transitional Vertebra (LSTV) that is congenital and usually presents into a patients 20’s or 30’s. The fusion can vary being full or partial and this creates the presence of the transitional vertebra. It can cause pain that presents similarly to sciatica due to the irritation of the 5th nerve root and also can radiate along the buttocks and in some cases down the leg. Owing to the fusion of the spine and reduced mobility, strain is then placed on other segments superior (on top of) the 5th vertebra and disc issues here are common as the segments try to compensate for the lack of movement in the lower articulation. Scoliosis is also commonly associated with the condition especially in a unilateral (one sided) fusion.
This lumbago (pain in the lower spine) is often not diagnosed immediately as so many people don’t know that they have a LSTV condition. It often doesn’t affect those who have the condition (only 13% of people with LSTV have pain symptoms) so having a LSTV doesn’t equate to developing Bertolotti’s Syndrome. But in cases that do, the pain can radiate across the lower back generically and sometimes reach the buttocks. Often general pain medication and treatment can provide some temporary relief but the condition presents with more challenging issues than generic treatment can address.
The reduced mobility of the joint and the bone on bone articulation creates movement issues in the lower spine and this presents as pain that can be associated with the Sacroilliac pain, hip issues and even in the groin. The radicular pain pattern is so similar to sciatica that this is a common misdiagnosis that is only eliminated upon further investigation with radiographs or MRI’s to determine the bony fusion.
The fusion itself creates biomechanical changes. Increased abnormal torque movements (twisting and rotation) are noted at the sites above the fusion and this places abnormal stress on the discs in L4/L3 and above which leads to early onset of damage. Oddly, hypermobility in other sites is also a result of the fusion as the body compensates in other areas for the lack of movement at a particular site. As mentioned, scoliosis (a sideways deviation fo the spine) is also commonly associated with the condition as the body tries to complete movement and gait motions with the reduced mobility on one side.
The origin of the pain and whether the nerve root irritation or the reduced mobility is the source of pain is often determined via steroidal injection. Local steroids and anaesthetics are used to determine whether the cause of pain is directly at the articulation or whether the nerve root of L4/5 is the cause of irritation. In the case of the pseudoarticulation, local steroid injection usually results in a relief of symptoms however nerve root cause will require more advanced surgery.
Treating the condition is determined by what is the presenting pain issue. The articulation itself may not be causing the pain and the associated pain can come from compensatory patterns. Conditions of this type include facet joint degredation as well as Sacroillitis (inflammation of the Sacroilliac Joint) and are treated seperately to the articular issue. Surgical intervention is most common the best way to address the articulation issues by numbing the disc or administering steroidal injection which helps to decrease the inflammation of the nerve root. This provides temporary relief for anywhere from 2-6 years.
Non surgical management is prescribed and in some cases this can have a mild success rate. Mobilisation of the spinal segments is one such approach, helping to create as much movement as possible in the affected areas of the articulation and keeping the corresponding structures as mobile as possible. Neural stretching is also prescribed for sufferers as this helps to create more space for nerves and aim to decrease the irritation that is contributing to nerve pain. It is most effective when combined with other physical therapies but is known to help with decreasing nerve pain. As always the STRONG CORE is also prescribed for any lower back conditions. The idea here is to create strength around the compromised area and ask the network of muscles, fascia and connective tissue that makes up the core to help in stabilising the spine and preventing unwarranted movement or compression in the area.
The onset of Bertolotti’s condition is often nominated at 20-30 years for sufferers but can present in ages older as well. Its the consistent nature of the pain and often it takes an elimination of other considerations before practitioners may start to investigate the presence of a LSTV. It is one of the many considerations that can be nominated in the presence of radiating and consistent pain which doesn’t seem to respond to normal physical therapy approaches. Radiography and investigation by Doctors is the best path to detemine this condition and approach the treatment regime.
